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Cohen PA, Anderson L, Eva L, Scurry J. Clinical and molecular classification of vulvar squamous pre-cancers. Int J Gynecol Cancer 2019; 29:821-828. [PMID: 30737358 DOI: 10.1136/ijgc-2018-000135] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2018] [Revised: 01/11/2019] [Accepted: 01/15/2019] [Indexed: 12/25/2022] Open
Abstract
Vulvar intraepithelial neoplasia (VIN) is a precursor to vulvar squamous cell carcinoma and is defined histopathologically by the presence of atypia. VIN has been classified into two types: usual vulvar intraepithelial neoplasia (uVIN), which is also referred to as a vulvar high-grade squamous intra-epithelial lesion (HSIL), and differentiated VIN (dVIN). The former is associated with chronic infection by sub-types of the human papilloma virus (HPV), whereas dVIN is HPV-independent and frequently associated with lichen sclerosus. The distinction is important because dVIN has a greater risk of, and more rapid transit to, vulvar squamous cell carcinoma. Furthermore, dVIN-associated vulvar cancers have an increased risk of recurrence and higher mortality than those arising from HSIL. Molecular characterization of vulvar squamous cell carcinoma precursors using next-generation sequencing is a relatively novel, but rapidly advancing field. This review appraises recent studies that have investigated the risks of progression to vulvar malignancy associated with HSIL and dVIN, the prognosis of HPV-dependent and HPV-independent vulvar squamous cell carcinomas, and conducted next generation sequencing mutation analyses to elucidate the genomic profiles underlying VIN. These studies suggest that HSIL and dVIN are characterized by different underlying molecular alterations that may have important implications for treatment and follow-up of women diagnosed with vulvar squamous cell cancer.
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Affiliation(s)
- Paul A Cohen
- Department of Gynaecological Oncology, St John of God Hospital Bendat Family Comprehensive Cancer Centre, Perth, Western Australia, Australia .,Division of Obstetrics and Gynaecology, Faculty of Health and Medical Sciences, University of Western Australia, Crawley, Western Australia, Australia
| | - Lyndal Anderson
- Anatomical Pathology Department, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia.,School of Medicine, Western Sydney University, Penrith South, New South Wales, Australia
| | - Lois Eva
- Department of Gynaecological Oncology, National Women's Health, Auckland City Hospital, Auckland, New Zealand.,Department of Gynaecological Oncology, University of Auckland, Auckland, New Zealand
| | - James Scurry
- Pathology North, New Lambton Heights, New South Wales, Australia.,Faculty of Health and Medicine, University of Newcastle, Newcastle, New South Wales, Australia
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Tumor cell-specific Serpin A1 expression in vulvar squamous cell carcinoma. Arch Gynecol Obstet 2019; 299:1345-1351. [PMID: 30607583 PMCID: PMC6475512 DOI: 10.1007/s00404-018-5015-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2018] [Accepted: 12/08/2018] [Indexed: 11/30/2022]
Abstract
Purpose The two main etiological factors for vulvar squamous cell carcinoma (vSCC) are the vulvar dermatosis lichen sclerosus (LS) and high-risk human papillomavirus (hrHPV). Serpin A1 (α1-antitrypsin) is a serine protease inhibitor, which plays a role in the tumorigenesis of various cancer types. The aim of the study was to evaluate the expressions of Serpin A1 in LS, premalignant vulvar lesions, and vSCC using immunohistochemistry (IHC) and serum analysis, and to compare Serpin A1 stainings to the tumor markers p53 and p16. Methods In total, 120 samples from 74 patients were studied with IHC for Serpin A1, p53 and p16: 18 normal vulvar skin, 53 LS, 9 premalignant vulvar lesions (dVIN/HSIL) and 40 vSCC samples. Serum concentrations of Serpin A1 were analyzed from 30 LS, 44 vSCC and 10 control patients. Expressions were compared to clinical data. Results Tumor cell-specific Serpin A1 overexpression was detected in 88% of vSCC samples, independent of the etiology. The intensity of Serpin A1 expression was significantly higher in vSCC than in healthy vulvar skin, LS, or premalignant vulvar lesions. Serpin A1 showed an association with p53 positivity. No difference in overall survival was found between Serpin A1-, p53-, or p16-positive vSCC patients. Serum concentrations of Serpin A1 were equal in the LS, vSCC, and control groups. Conclusion Tumor cell-specific Serpin A1 overexpression is a potential biomarker in vSCC.
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Dohopolski MJ, Horne ZD, Pradhan D, Bhargava R, Edwards RP, Kelley JL, Comerci JT, Olawaiye AB, Courtney-Brooks M, Berger JL, Sukumvanich P, Beriwal S. The Prognostic Significance of p16 Status in Patients With Vulvar Cancer Treated With Vulvectomy and Adjuvant Radiation. Int J Radiat Oncol Biol Phys 2019; 103:152-160. [DOI: 10.1016/j.ijrobp.2018.08.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 07/28/2018] [Accepted: 08/04/2018] [Indexed: 01/25/2023]
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Human papillomavirus infection mediates response and outcome of vulvar squamous cell carcinomas treated with radiation therapy. Gynecol Oncol 2018; 151:96-101. [DOI: 10.1016/j.ygyno.2018.08.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Revised: 07/27/2018] [Accepted: 08/01/2018] [Indexed: 02/04/2023]
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HPV-independent Differentiated Vulvar Intraepithelial Neoplasia (dVIN) is Associated With an Aggressive Clinical Course. Int J Gynecol Pathol 2018; 36:507-516. [PMID: 28319571 DOI: 10.1097/pgp.0000000000000375] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Differentiated vulvar intrapeithelial neoplasia (dVIN) is an human papillomavirus (HPV)-independent precursor of squamous cell carcinoma (SCC), and the aim of this study was to better characterize its natural history. Cases of dVIN were identified from the pathology archives. Outcomes of patients with dVIN only, without associated invasive SCC, were compared with a cohort of patients with high-grade squamous intraepithelial lesion [HSIL(VIN3)]. Eighteen patients diagnosed with dVIN with adjacent invasive SCC (SCC/dVIN) and 7 patients with dVIN only, without invasive carcinoma, were identified. Mean age in both cohorts was 75 yr. All lesions but 1 were unifocal. In 35% of SCC/dVIN cases the surgical resection margins were positive for SCC, with 75% and 60% having margins positive for dVIN in the SCC/dVIN and dVIN-only cohorts, respectively. In total, 23/25 women with dVIN only or dVIN/SCC, for whom there was follow-up information, experienced either progression to or recurrence of invasive SCC, respectively, at a median of 1.1 yr, including all but 1 case of dVIN only, where the median time of progression to invasive SCC was 1.9 yr. A total of 22/25 women died of disease with a median overall survival of 3.4 yr. The outcome (i.e. progression to invasive carcinoma) of patients with dVIN only was significantly worse than that of a comparison group of 18 patients with HSIL(VIN3) (progression-free survival log-rank, P<0.001; disease-specific survival, P=0.04; overall survival, P=0.01). Six of 7 patients with dVIN only developed invasive carcinoma on follow-up, compared with 0 of 18 patients with HSIL(VIN3). The diagnosis of dVIN indicates the presence of a high-risk human papillomavirus-negative precursor of invasive SCC. These patients are likely to progress to invasive carcinoma over a relatively short period, at which point their prognosis is guarded.
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Does Differentiated Squamous Intraepithelial Neoplasia Occur in the Cervix? Appl Immunohistochem Mol Morphol 2017; 26:e52-e60. [PMID: 28877072 DOI: 10.1097/pai.0000000000000577] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND Invasive cervical cell squamous carcinoma (ICC) classically develops from high grade cervical intraepithelial neoplasia of usual type (uCIN). Differentiated cervical intraepithelial neoplasia (dCIN) analogue to differentiated vulvar intraepithelial neoplasia has not been described in the cervix. METHODS A pilot case of ICC developing from dCIN with atypia limited to the basal/parabasal layers, focally associated with neoplastic spread above the parabasal layer (usual-like CIN pattern or u-like CIN) was identified. The previous cervical biopsy was under-diagnosed as low grade CIN. A total of 33 consecutive cases of ICC were reviewed to identify dCIN, u-like CIN and uCIN. RESULTS The ICC developed from dCIN/u-like CIN in 2 patients, 46 and 47-year-old (group 1), mixed dCIN/u-like CIN and uCIN in 7 patients, 36±3-year-old (group 2) and from uCIN in 24 patients, 47±9-year-old (group 3). In group 1, focal uCIN but not connected to ICC was also seen and Pap smears showed only hyper-keratinized cells with mildly atypical nuclei. Endocervical gland involvement by CIN was absent in group 1, focal in group 2 and extensive in group 3. All cases showed diffuse p16 staining. P53 reactivity was noted in basal/parabasal in dCIN, predominantly lower and upper parts of the epithelium in groups 2 and 3, respectively. CONCLUSIONS Totally, 27% of ICC cases had associated dCIN/u-like CIN and in younger patients than in the uCIN group. Larger studies are needed to confirm dCIN/u-like CIN as significant precursor lesions of ICC.
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Rakislova N, Clavero O, Alemany L, Saco A, Quirós B, Lloveras B, Alejo M, Pawlita M, Quint W, del Pino M, de Sanjose S, Ordi J. "Histological characteristics of HPV-associated and -independent squamous cell carcinomas of the vulva: A study of 1,594 cases”. Int J Cancer 2017; 141:2517-2527. [DOI: 10.1002/ijc.31006] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Revised: 08/03/2017] [Accepted: 08/07/2017] [Indexed: 12/17/2022]
Affiliation(s)
- Natalia Rakislova
- Department of Pathology; ISGlobal, Hospital Clínic - Universitat de Barcelona; Barcelona Spain
| | - Omar Clavero
- Unit of Infections and Cancer; Cancer Epidemiology Research Program, Catalan Institute of Oncology, IDIBELL, L'Hospitalet de Llobregat; Barcelona Spain
| | - Laia Alemany
- Unit of Infections and Cancer; Cancer Epidemiology Research Program, Catalan Institute of Oncology, IDIBELL, L'Hospitalet de Llobregat; Barcelona Spain
- CIBER Epidemiologia y Salud Pública; Barcelona Spain
| | - Adela Saco
- Department of Pathology; ISGlobal, Hospital Clínic - Universitat de Barcelona; Barcelona Spain
| | - Beatriz Quirós
- Unit of Infections and Cancer; Cancer Epidemiology Research Program, Catalan Institute of Oncology, IDIBELL, L'Hospitalet de Llobregat; Barcelona Spain
| | - Belen Lloveras
- Department of Pathology; Hospital del Mar; Barcelona Spain
| | - Maria Alejo
- Department of Pathology; Hospital General d'Hospitalet, L'Hospitalet de LLobregat; Barcelona Spain
| | - Michael Pawlita
- Division of Molecular Diagnostics of Oncogenic Infections, Research Program Infection, Inflammation and Cancer; German Cancer Research Center (DKFZ); Heidelberg Germany
| | - Wim Quint
- DDL Diagnostic Laboratory; Rijswijk The Netherlands
| | - Marta del Pino
- Faculty of Medicine, Institute of Gynecology, Obstetrics and Neonatology, Hospital Clínic - Institut d´Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), University of Barcelona; Barcelona Spain
| | - Silvia de Sanjose
- Unit of Infections and Cancer; Cancer Epidemiology Research Program, Catalan Institute of Oncology, IDIBELL, L'Hospitalet de Llobregat; Barcelona Spain
- CIBER Epidemiologia y Salud Pública; Barcelona Spain
| | - Jaume Ordi
- Department of Pathology; ISGlobal, Hospital Clínic - Universitat de Barcelona; Barcelona Spain
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Abstract
Human papillomavirus (HPV) is involved in one of the at least 2 pathways leading to vulvar squamous cell carcinoma (VSCC). Inactivation of p53 and retinoblastoma by the viral products E6 and E7 is involved in malignant transformation. The percentage of HPV-positive VSCCs ranges from 18% to 75%, depending on the geographical area. HPV-associated tumors affect relatively young women and arise from high-grade intraepithelial lesions, identical to other HPV-associated premalignant lesions of the anogenital tract. HPV-independent tumors tend to affect older women and usually arise in a background of inflammatory skin disorders and a subtle variant of in situ lesion called differentiated vulvar intraepithelial neoplasia. HPV-positive tumors tend to be of basaloid or warty types, whereas HPV-independent tumors tend to be of keratinizing type, but there is frequent overlap between histologic types. There is no conclusive evidence yet on the best strategy in terms of determining HPV attribution. HPV DNA detection is generally considered the gold standard although there is some concern about misclassification when using this technique alone. p16 immunostaining has shown to be an excellent surrogate marker of HPV infection. Positive results for both techniques are considered the best evidence for HPV-association. The prognostic role of HPV in VSCC is still contradictory, but increasing evidence suggests that HPV-associated tumors are less aggressive. Currently, there are no differences in treatment between HPV-associated and HPV-independent VSCC, but novel immunological strategies based on anti-HPV antigens are being evaluated in clinical trials.
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Uryu M, Furue M. p16 INK4a Expression in Porokeratosis. Ann Dermatol 2017; 29:373-376. [PMID: 28566925 PMCID: PMC5438955 DOI: 10.5021/ad.2017.29.3.373] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Revised: 05/16/2016] [Accepted: 06/27/2016] [Indexed: 11/08/2022] Open
Affiliation(s)
- Miki Uryu
- Department of Dermatology, Kyushu University, Fukuoka, Japan
| | - Masutaka Furue
- Department of Dermatology, Kyushu University, Fukuoka, Japan.,Division of Skin Surface Sensing, Department of Dermatology, Kyushu University, Fukuoka, Japan.,Research and Clinical Center for Yusho and Dioxin, Kyushu University, Fukuoka, Japan
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McAlpine JN, Leung SCY, Cheng A, Miller D, Talhouk A, Gilks CB, Karnezis AN. Human papillomavirus (HPV)-independent vulvar squamous cell carcinoma has a worse prognosis than HPV-associated disease: a retrospective cohort study. Histopathology 2017; 71:238-246. [PMID: 28257152 DOI: 10.1111/his.13205] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Accepted: 02/27/2017] [Indexed: 11/30/2022]
Abstract
AIMS Vulvar squamous cell carcinoma (VSCC) can be subdivided by human papillomavirus (HPV) status into two clinicopathological entities. Studies on the prognostic significance of HPV in VSCC are discordant. METHODS AND RESULTS We performed a retrospective analysis of overall survival (OS), disease-specific survival (DSS) and progression-free survival (PFS) in 217 patients with VSCC. Cases were extracted from an era of more aggressive en-bloc radical dissections (1985-95) and more localized radical surgery through separate vulvar and groin excisions (1996-2005). p16 immunohistochemistry was used as a surrogate for HPV status. HPV status could be determined in 197 tumours, 118 HPV-independent and 79 HPV-associated tumours. Patients with HPV-associated tumours were younger (mean 58.8 versus 71.6 years for HPV-independent tumours, P < 0.0001) and more likely to have prior abnormal cervical cytology (41.1 versus 5.6% for HPV-independent tumours, P < 0.0001). In univariable analysis, patients with HPV-associated tumours had superior PFS [hazard ratio (HR): 0.37, 95% confidence interval (CI): 0.18-0.70], DSS (HR: 0.19, 95% CI: 0.08-0.41) and OS (HR: 0.35, 95% CI: 0.21-0.59). This was driven by worse outcomes (PFS, DSS and OS) for patients with HPV-independent tumours compared with HPV-associated tumours who underwent surgery after 1995. After adjusting for age and stage in multivariable analysis, patients with HPV-associated tumours showed superior PFS (HR: 0.25, 95% CI: 0.07-0.77) and DSS (HR: 0.21, 95% CI: 0.04-0.78). CONCLUSIONS VSCC can be stratified into two prognostically different diseases based on p16 immunostaining. HPV status was associated only with prognosis in the cohort that underwent surgery after 1995, suggesting that more conservative surgery may have led to worse outcomes for patients with HPV-independent tumours.
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Affiliation(s)
- Jessica N McAlpine
- Division of Gynecologic Oncology, Department of Gynecology and Obstetrics, University of British Columbia, Vancouver, BC, Canada
| | - Samuel C Y Leung
- Department of Pathology and Laboratory Medicine, Genetic Pathology Evaluation Centre, University of British Columbia, Vancouver, BC, Canada
| | - Angela Cheng
- Department of Pathology and Laboratory Medicine, University of British Columbia and BC Cancer Agency, Vancouver, BC, Canada
| | - Dianne Miller
- Division of Gynecologic Oncology, Department of Gynecology and Obstetrics, University of British Columbia, Vancouver, BC, Canada
| | - Aline Talhouk
- Department of Pathology and Laboratory Medicine, University of British Columbia and BC Cancer Agency, Vancouver, BC, Canada
| | - C Blake Gilks
- Department of Pathology and Laboratory Medicine, University of British Columbia and Vancouver General Hospital, Vancouver, BC, Canada
| | - Anthony N Karnezis
- Department of Pathology and Laboratory Medicine, University of British Columbia and BC Cancer Agency, Vancouver, BC, Canada
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Singh N, Gilks CB. The changing landscape of gynaecological cancer diagnosis: implications for histopathological practice in the 21st century. Histopathology 2017; 70:56-69. [PMID: 27960241 DOI: 10.1111/his.13080] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
The era of molecular medicine has led to dramatically improved understanding of the genetic events that give rise to different types of cancers. In the case of gynaecological malignancies, this has resulted in distinct shifts in how these tumours are diagnosed in routine surgical pathology practice, with an increased emphasis on accurate subtype diagnosis. This has happened across all sites in the gynaecological tract and for most cell types, but in ways that are site-specific and may appear to be subtle, as in most instances the diagnostic terminology has not changed. For example, the diagnosis of clear cell carcinoma of the ovary is still in use, but the diagnostic criteria and clinical implications are different in 2017 from what they were in 2000. As a result, there can be a failure to appreciate how important these changes are and the resulting necessity of incorporating them into our daily practice. In this review we will describe changes in diagnostic surgical pathology occasioned by improved understanding of molecular events during pathogenesis, for cancers of ovary/tube, endometrium, cervix and vulva, and highlight how current practice differs from that of only a few years ago.
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Affiliation(s)
- Naveena Singh
- Department of Cellular Pathology, Barts Health NHS Trust, London, UK
| | - C Blake Gilks
- Department of Anatomic Pathology, Vancouver General Hospital, Vancouver, BC, Canada
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Hoang LN, Park KJ, Soslow RA, Murali R. Squamous precursor lesions of the vulva: current classification and diagnostic challenges. Pathology 2016; 48:291-302. [PMID: 27113549 PMCID: PMC5518939 DOI: 10.1016/j.pathol.2016.02.015] [Citation(s) in RCA: 105] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2016] [Revised: 02/08/2016] [Accepted: 02/12/2016] [Indexed: 01/11/2023]
Abstract
Growing evidence has established two major types of vulvar intraepithelial neoplasia (VIN), which correspond to two distinct oncogenic pathways to vulvar squamous cell carcinoma (VSCC). While the incidence of VSCC has remained relatively stable over the last three decades, the incidence of VIN has increased. VIN of usual type (uVIN) is human papillomavirus (HPV)-driven, affects younger women and is a multicentric disease. In contrast, VIN of differentiated type (dVIN) occurs in post-menopausal women and develops independent of HPV infection. dVIN often arises in a background of lichen sclerosus and chronic inflammatory dermatoses. Although isolated dVIN is significantly less common than uVIN, dVIN bears a greater risk for malignant transformation to VSCC and progresses over a shorter time interval. On histological examination, uVIN displays conspicuous architectural and cytological abnormalities, while the morphological features that characterise dVIN are much more subtle and raise a wide differential diagnosis. On the molecular level, dVIN is characterised by a higher number of somatic mutations, particularly in TP53. Here we review the classification, epidemiology, clinical features, histomorphology, ancillary markers and molecular genetics of both types of VIN, and discuss the morphological challenges faced by pathologists in interpreting these lesions.
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Affiliation(s)
- Lien N Hoang
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Kay J Park
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Robert A Soslow
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Rajmohan Murali
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Marie-Josee and Henry R. Kravis Center for Molecular Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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